"Painless" lidocaine injection

[bulgethetwine]

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The scenario: 5 year old kid, a chin lac needing 6 x 6.0 vicryl. He doesn't speak english, so you have to coax and cajole using his 9 year old brother as translator (Mom and Dad don't speak much english). You spend an hour letting the LET bake on his chin, then gently coach him to let you inject lidocaine. He howls a bit, but somehow tolerates enough of it to be numb. You do all the "right" things: 30 guage needle, into the wound edge, injecting even before you hit tissue, slow so as not to burn it too much. He cries, but tolerates it well.

Your attending decides he wants to put in the first subcutaneous stitch.

Uh-Oh.

After you've hid the needle the whole time (imploring him to keep his eyes closed as per his brother's translation as you inject) your attending -- a strange face -- comes at the 5 year old with a Kelly and cutting needle.

The kid bites your attending, who, in his surprise, stabs himself in the chin, blood running down his face. Attending now thinks it's YOUR FAULT because you didn't inject the lidocaine painlessly enough, the insinuation that you frightened the little beggar so much that it caused him to bite your attending.

The end game involves ketamine...

The attending no thinks i'm an absolute amateur as far as suturing goes... and he may be right, I sure as hell am not an expert at anything. Anyone wanna tell me their "painless" injection strategies?

 

[DrQuinn]

Not sure why the kid jumped with your attending if you used LET and 1%...

Other things:

You can TRY using a bit of bicarb. I used to do it as a student at Einstein in Philly because they had little bottles o' bicarb in their lac tray. At TGH if I ask for bicarb from the nurses, they give me the big CODE sized syringe. 10:1 lidocaine : bicarb.

You can warm the lidocaine in the microwave, apparently. None lying around. Maybe I'll try leaving a bottle of lidocaine in the blanket warmer...

I distract patients sometimes if I'm going to numb them. Basically if you tell someone you're going to stick them and its going to burn... tap them maybe 2-3 inches away from where you're going to inject. They will focus their attention on THAT area, thinking you're going to inject them there... then when they get stuck somewhere else, it doesn't "seem" as bad. This works on adult patients, anyways. I'm sure there's some neuropsych thing behind it.

Drop the bee sting. NO ONE likes bees, and no one likes to get stung by a bee. Imagine if you were 4 years old!

Q

 

[VienneseWaltz]

Not sure why the kid jumped with your attending if you used LET and 1%...

Q

I think bulge was saying that the kid jumped at the sight of the needle, before the first stitch (which is why the attending stabbed himself). The attending thought the lidocaine was too painful, not that it wasn't enough.

 

[Jambi]

It's been my experience that kids don't like new, sudden faces. I think that most kids in the ED know that something that they are not going to like is going to happen to them.

 

[NinerNiner999]

Not to sound too callous, but 90% of the time I papoose the kid, tell the parents that it will look and sound painful (but it isn't), and go for the gold. It always helps if parents hold the head. For lip lacs, I let the kid bite on a yankaur while I inject and repair. I think the kid is going to cry no matter what, and the quicker you get lido on board, the quicker things go in general. I used to really take my time, prep the kid, use the Bicarb mix, wait for LET, etc, but I think after my own randmized control study of the kids I've done, it may only save me a minute or so total from the whole procedure...

 

[colforbinMD]

I would add the importance of a small guage needle (keep it unseen if you can) and a slow rate of injection from inside the wound out. Simple beginers instructions but when I forget them it is inevitably worse for the pt. and by extension me.
I like the bicarb buffer for kids too. And telling the kid it's time to play the mummy game as I papoose him. Once he realizes he can't move he is not so into it but it makes it easier to get to that point if he thinks of it as a mummy costume.

 

[DrQuinn]

Not to sound too callous, but 90% of the time I papoose the kid, tell the parents that it will look and sound painful (but it isn't), and go for the gold. It always helps if parents hold the head. For lip lacs, I let the kid bite on a yankaur while I inject and repair. I think the kid is going to cry no matter what, and the quicker you get lido on board, the quicker things go in general. I used to really take my time, prep the kid, use the Bicarb mix, wait for LET, etc, but I think after my own randmized control study of the kids I've done, it may only save me a minute or so total from the whole procedure...

I always learned that you shouldn't have the parents be a part of the "restrain team." The kids will then resent their parents for helping give them pain. They should be in the room and should be there for support, but you should have the nurse do the dirty work. Then when you are done, you lift off the sterile field, and say "go to your mommy." and now mommy is the hero.

Q

 

[roja]

1. Kid resenting the parent? A myth by non parents. I papoosed my kid with an attending and her favorite nurse (she visits the ED) and she likes us all still.

2. Papoose. Kids are scared. You cant rationalize with them. Its nicer to just tie them up. Its over faster and they will forget by the time the parents have given them thier next meal.

3. Nitrous. We have started using this and it ROCKS. It is amazing. I am in love with our machine. Lord help me if I end up somewhere that doesn't have it.

4. The attending sounds like a bone head. ( no offence, but does this person SEE kids on a regular basis?) Jumps in at the last minute and decides to throw the first stitch? And what is throwing one stitch?

Okay, I'm punching because I've been working overnights and I am working 12/14.


I'm going back to bed.

 

[Seaglass]

You can TRY using a bit of bicarb. I used to do it as a student at Einstein in Philly because they had little bottles o' bicarb in their lac tray. At TGH if I ask for bicarb from the nurses, they give me the big CODE sized syringe. 10:1 lidocaine : bicarb.Q

Try asking for "neut" - thats a brand name of bicarb in little vials for buffering. Until I started asking for it I got the same response as you.

 

[colforbinMD]

3. Nitrous. We have started using this and it ROCKS. It is amazing. I am in love with our machine. Lord help me if I end up somewhere that doesn't have it.

Doesn't it make it hard to suture though? I would think you'd be either too busy giggling or falling asleep in your sterile field? 🙂

Okay, I'm punching because I've been working overnights and I am working 12/14.


I'm going back to bed.

A bit cranky from the N2O withdrawl me thinks!! 😀

 

[toofache32]

I'll give my quick 2 cents as a dentist/oral surgery resident who hits people with lidocaine all day every day.

1. I agree that you can't rationalize with a kid. I've tried it many times and it only worked once with a mature 9-year-old who let me sew his eyebrow without sedation. If it's available, sedation rules...whether it's a ketamine dart or nitrous. The thing kids fear the most is the "unknown", which is everything we do to them, needles or not.

2. One advantage in the head & neck area is cranial nerves. You can block an entire field with one injection. This also gives you anesthesia to larger areas which lessens the chance of lidocaine toxicity. Then you can painlessly inject around the wound just for hemostasis even though I usually just let it bleed unless its gushing. I think it hurts more to inject around the wound because of the inflammation that's already there. I sewed up my own foot once when I gashed it on a rock, and it hurt like hell to inject. I injected one side and almost stopped because I didn't want to inject the other side.

For the chin, I usually hit the mental nerves in the mouth just below and between the premolars. The gingiva can be injected less painfully there because it can be stretched taught which lessens the pain for some reason.

Here's a great article to learn your cranial nerve blocks:

How to block and tackle the face. Plast Reconstr Surg. 1998 Mar;101(3):840-51.

3. There are several tricks to "painless" injections. Most involve distraction. Some people push very firmly with a blunt hard instrument (blade handle) and inject right next to it. For some reason the blunt pushing obscures the pain of the injection. But sometimes this is still tough in kids.

Just my 2 cents. Hope this helps.

 

[GeneralVeers]

I'll give my quick 2 cents as a dentist/oral surgery resident who hits people with lidocaine all day every day.

I love watching the oral surgeons and helping them out when they come to the ER. They have shown me some cool tricks. One patient was having a through and through laceration to the corner of his lips repaired, and I learned how to do a nerve block to the branch of V2 (by injecting 2 cm above the canine on that side). Pretty cool stuff.

 

[Hawkeye Kid]

Along the lines of papoosing, here are a few little games I picked up from one of the PAs during my time as an ED tech:

1. Superman. Have the kid stand up and put a pillowcase behind them, then put their arms in it. When they lay down, they're basically restraining themselves.

2. Human burrito. Essentially just wraping them in a sheet, sometimes after they play superman. Again, self-restraint.

By the time they realize what they're doing, you've got them tied down. With the traditional papoose board, they sense what's going on and fight you the whole time. When you make a game out of it, they usually go along with you long enough to get it done. Besides, it seems like most kids can wiggle out of the papoose, in my experience, while the human burrito is pretty childproof. Of course, they need to be old enough to know about Superman and mexican food, but it's still better than nothing...

 

[toofache32]

Of course, they need to be old enough to know about Superman and mexican food, but it's still better than nothing...

Around here in Texas, most kids learn about Mexican food sometime around the 12th week in utero.

 

[sweetfynesse]

I am a big fan of Midazolam (Versed) 0.25 to 0.75 mg/kg usually 0.50-0.75mg/kg for anxiolytic, whether for sutures or CT. It doesnt qualify for moderate sedation, its safe, and it works wonders...no more brutain for me (ie "brute force", "papoose")

 

[Energon]

Yea, doing injections on kids, especially intraorals is a pretty hard thing. Kids in general hate new faces, especially attendings who seem to be in a hurry and think they establish a great rapport with kids throwing around the word "buddy", or "sport" a couple hundred times.

1. I usually talk to the kid in a calm/soothing voice for a few minutes prior to doing anything.
2. Guage the parent or adult who brought the child, sometimes they do more harm by projecting thier fears. I usually have them leave the room.
3. After talking to the kid and getting him/her calm have them put their head back or keep them supine.
4. Approach from an 11o'clock position (if you are right handed) obstruct their line of vision with your left hand while you administer the anesthetic. You can also use your left hand to simultaneously brace the childs face so there is no sudden jerk.

I also like to move the cheek around (pulling/ tugging on it with the index finger and thumb) while administering a mental nerve block. It distracts the kid and the anesthetic dissipates better in the buccal soft tissue

Alwyas have a nurse assisting, so he/she can keep an eye on the kids hands. If the child is somewhat cooperative, have him/her sit on their hands "hands under butt" while you administer the anesthetic.